This example demonstrates a well-structured SOAP note from a Nurse Practitioner (NP) for a patient presenting with common symptoms. Remember, this is for illustrative purposes only and should not be used as a template for actual patient care. Always adhere to your facility's specific guidelines and legal requirements for documentation.
Patient: Jane Doe, 45-year-old female
Date: October 26, 2023
Encounter: Follow-up visit
S: Subjective
Patient presents today for a follow-up appointment regarding persistent cough and fatigue. She reports the cough began three weeks ago, initially dry but now producing some clear sputum. She denies fever, chills, or shortness of breath. She describes the fatigue as persistent and debilitating, impacting her ability to perform daily activities. She reports sleeping 8-9 hours per night but still feeling tired upon waking. She denies chest pain, hemoptysis, or weight loss. She reports increased stress levels at work recently due to a new management structure. She denies any known allergies. She denies recent travel or exposure to sick individuals.
O: Objective
- Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 98.6°F (oral), SpO2 99% on room air.
- HEENT: Normocephalic, atraumatic. Perrla. Oropharynx clear. No lymphadenopathy.
- Neck: Supple, no thyromegaly.
- Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
- Heart: Regular rate and rhythm, no murmurs, rubs, or gallops.
- Abdomen: Soft, non-tender, non-distended. Bowel sounds present in all four quadrants.
- Extremities: No edema. Full ROM.
- Neurological: Alert and oriented x3. Cranial nerves II-XII intact. Strength 5/5 bilaterally. Normal gait.
A: Assessment
- Likely Diagnosis: Acute bronchitis, likely viral in etiology. Consideration of stress-related fatigue.
- Differential Diagnoses: Pneumonia, upper respiratory infection, chronic fatigue syndrome. These are less likely given the presentation.
P: Plan
- Treatment: Symptomatic treatment advised, including increased fluid intake, rest, and over-the-counter cough suppressant (e.g., dextromethorphan) as needed for cough. No antibiotics prescribed as the likely etiology is viral. Encouragement of stress-reduction techniques like yoga or meditation was discussed.
- Follow-up: Patient will follow up in one week if symptoms don't improve or worsen, or sooner if needed.
- Patient Education: Educated the patient on the importance of rest, hydration, and symptom management. Provided information on stress-reduction techniques and resources. Discussed the possibility of a referral to a therapist if needed.
- Referral: Consideration of referral to a therapist if symptoms of stress-related fatigue persist.
Note: This is a sample SOAP note and should not be used for actual patient care. Each SOAP note should be tailored to the individual patient and clinical situation. This example contains information that would likely be included in a more complete and detailed note, which might contain further details on the patient's medical history, family history, etc.
Frequently Asked Questions (PAA) – Addressing Common Queries
What are the key components of a SOAP note?
A SOAP note consists of four key components: Subjective (patient's statement of symptoms), Objective (physical examination findings and other objective data), Assessment (diagnosis and clinical impression), and Plan (treatment plan, further investigations, follow-up).
How do I write a good subjective section of a SOAP note?
The subjective section should accurately reflect the patient's own words and experiences, including their chief complaint, history of present illness (HPI), past medical history, medication history, allergies, family history, and social history, using direct quotes whenever possible for clarity and accuracy.
What objective data should be included in a SOAP note?
The objective section should include vital signs, physical examination findings, and results of any diagnostic tests performed (e.g., lab results, imaging studies). This section should be factual and quantifiable, avoiding subjective opinions.
How detailed should the assessment section be in a nurse practitioner's SOAP note?
The assessment section should clearly and concisely state the most likely diagnosis(es), including any differential diagnoses considered. The reasoning behind the diagnosis should be supported by evidence from the subjective and objective sections.
What should be included in the plan section of a SOAP note?
The plan section outlines the treatment strategy, including medications, therapies, referrals, further diagnostic tests, and patient education. It also specifies the plan for follow-up care.
This expanded answer incorporates frequently asked questions, providing a more comprehensive and helpful resource for readers. Remember to always consult your institution’s guidelines and legal counsel when documenting patient care.
